Anticipating the Unpredictable

Dana Orquiza

When violent events occur, confusion and grief ripple from the epicenter of the event to the edges of communities and beyond. Helplessness drives fear. Anger rises. Blame becomes its own weapon.


We’ve seen it time and again as the shootings in schools, hospitals, and even churches seem to increase and escalate. The recent catastrophe at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina tore nine people from their families and loved ones. The nation continues to reel from the violence.


Hospitals are particularly vulnerable to the alarming possibility of encountering active shooters. On January 20, 2015, a surgeon at Boston’s Brigham and Women’s Hospital was shot and killed by a family member of a patient. It’s particularly unnerving to imagine violent behaviors occurring in spaces that are meant to serve as safe havens, places of healing.


Sadly, there is no way to prevent or predict when or where an active shooting may occur. There is no one profile specific to look for; there are no hard and fast rules. The United States Department of Homeland Security describes the active shooter simply as an individual actively engaged in killing or attempting to kill people in a confined and populated area. In most cases, active shooters use firearms and there is no pattern or method to their selection of victims.



Preparing for the Unthinkable

Education and training can help staff members recognize and report potential or actual situations in which an active shooter is involved. General training should include:


  • Individual roles and responsibilities
  • Threats, hazards, and protective actions
  • Notification, warning and communication procedures
  • Means for locating family members in an emergency
  • Emergency response procedures
  • Evacuation, shelter, and accountability procedures
  • Location and use of common emergency equipment
  • Emergency shutdown procedures


Simulations exercises are a recognized, effective risk mitigation strategy. In collaboration with local law enforcement, components of training simulations can include:


  • Learning to recognize the sound of gunshots
  • Reacting quickly when gunshots are heard or a shooting is witnessed
    • Practicing escape routes and evacuations
    • Finding hiding places
    • Acting against the shooter
  • Calling 911
  • Reacting when law enforcement arrives (calm, hands empty and in the air)
  • Adopting the survival mindset during a crises


Active shooter


Though unpredictable, the more thought, preparation, and collaboration that is given to responding calmly and methodically to an active shooter, the better for everyone. OSHA offers many useful ideas about how to effectively plan and prepare for such an event.


Responding Safely and Responsibly

An emergency checklist can be a helpful tool to ensure that there is a systematic and clear procedure to follow during an active shooting. Based in part on information from the Department of Homeland Security, such a checklist may include:


  • Escape if in immediate danger. Have a clear idea of your escape route and exit doors near you
  • Hide in an area that is out view, barricade your hiding place, and lock doors.
  • Silence all devices
  • Take action only as a last resort. Attempt to incapacitate the shooter using tools nearby
  • Remain aware and follow the instructions of law enforcement
  • Try to remain calm and refrain from making too much noise or inciting further panic


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When reporting the active shooter to law enforcement, keep in mind the following:

  • Report the active shooter to 911 if you are in a safe position to do so
  • It’s best to call 911 from a land line in case cell signals are jammed
  • Be sure to report to 911:
    • The shooter’s exact location (use full department names rather than abbreviations)
    • How many shooters (or potential shooters) there are
    • Give a physical description of the shooter
    • Tell them how many weapons you’ve seen and how many possible victims may have already been harmed


In the event of an emergency like an active shooting, preparation and planning can empower staff members with the ability to respond effectively and quickly, potentially keeping them from further harm.


As difficult as it may seem to cope with a violent attack, knowing what to do and what to look for, where to go and how to get there, may just make the difference.

Note: Please see my previously published webinar and white paper on this topic.


By: Dana Orquiza, RN, BSN, JD

Dana Orquiza is a healthcare risk management professional whose experience includes working as a medical-surgical nurse for over 10 years and as an associate attorney specializing in medical malpractice defense. Dana currently serves as Assistant Vice President of Risk Management of The Risk Authority, and as a director of risk management at Stanford University Medical Center. Her combination of clinical experience and legal expertise is instrumental in providing innovative risk management solutions designed to effectively reduce risk and identify opportunities to increase value.



Though the active shooter scenario is one that many fear in part because it creates feelings of powerlessness, there are steps individuals and organizations can take to prepare for and respond to attacks of this nature.